Remote DRG Clinical Validation Lead

Elevance Health; Walnut Creek (CA); Hybrid; USD 90,000 - 161,000; Full time

Benefits offered by this job

Comprehensive benefits

401(k) match

Stock purchase plan

Job summary

Elevance Health is seeking a DRG Clinical Validation Lead to ensure medically appropriate, high-quality, cost-effective care by evaluating medical necessity and treatment setting appropriateness. You will work with medical directors and clinicians to interpret benefits and ensure accurate claims payment.

This role may manage appeals and requires RN licensure with managed care experience. Hybrid/virtual with required in-person training.

Qualifications

• AS in nursing required; or equivalent background.
• 7+ years acute care clinical experience; prior managed care experience preferred.

Responsibilities

• Conduct pre-certification, retrospective, out of network and appropriateness reviews to ensure compliance with criteria and contracts.
• Ensure access to medically necessary, quality care in a cost-effective setting.
• Consult with clinical reviewers and medical directors to maintain appropriate, high-quality care across the management process.
• Collaborate with providers to identify discharge planning needs and proactive transitions.
• Facilitate member care transition and refer plans to reviewers; do not issue non-certifications.
• Support accreditation efforts by understanding and applying regulatory standards.
• Serve as team lead for complex medical issues and cross-functional initiatives.

Skills

RN license

acute care

managed care

Education

AS in nursing

Job description

Elevance Health is seeking a DRG Clinical Validation Lead to ensure medically appropriate, high-quality, cost-effective care by evaluating medical necessity and treatment setting appropriateness. You will work with medical directors and clinicians to interpret benefits and ensure accurate claims payment.

This role may manage appeals and requires RN licensure with managed care experience. Hybrid/virtual with required in-person training.